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Biomedical subjects

J E Krige

Publications and source records attributed to J E Krige.

At least 55 records · Page 3Linked to original sources
PubMed1997

The management of biliary complications following orthotopic liver transplantation.

OBJECTIVE: Review of the biliary complications following orthotopic liver transplantation (OLT) at our institution, and their management and outcome. DESIGN: Retrospective study of medical records of 63 patients who underwent 68 transplant operations. SETTING: The Liver Transplant Unit, Groote Schuur Hospital and Red Cross War Memorial Children's Hospital, Cape Town PATIENTS: Six patients treated for 9 biliary complications. INTERVENTIONS: Reoperation with biliary reconstruction, or non-operative measures by either endoscopic retrograde pancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). OUTCOME MEASURES: Clinical outcome and survival following treatment for biliary complications. RESULTS: Biliary complications occurred in 8.8% of patients who underwent transplantation at our institution. These consisted of strictures in 4 patients (with leak in 2), bile leak in 1 patient, and unsuspected primary sclerosing cholangitis (PSC) of the recipient duct in 1 patient. The mean time interval of biliary complications following OLT was 8 weeks (range 3-16). Biliary reconstruction was required in 4 patients while 2 patients were treated by endoscopic stenting. After a mean follow-up period of 30 months (range 1-64), 4 patients remained stable, 1 patient developed progressive stricturing of the intrahepatic ducts requiring repeated PTC dilatations, and 1 patient experienced stent blockages requiring endoscopic stent changes (died of unrelated causes). CONCLUSIONS: The rate of biliary complications following OLT at our institution compares favourably with literature reports. While biliary reconstruction is usually needed, endoscopic stenting appears effective in selected cases of biliary stricture and leak. PSC should be excluded prior to transplantation in young patients with cryptogenic cirrhosis.

Adolescent↗
PubMed1997

Endoscopic management of pancreatic pseudocysts.

BACKGROUND: Pancreatic pseudocysts may produce pain, or biliary or duodenal obstruction. Those over 6 cm in diameter or associated with chronic pancreatitis are unlikely to resolve and usually require intervention. There are a number of treatment modalities available and this paper reviews the role of endoscopic drainage. METHODS: All articles and case reports quoted on Medline (National Library of Medicine, Washington DC, USA) containing the text words 'endoscopy' and 'pseudocyst', and citations from these references were reviewed. RESULTS: Endoscopic drainage is technically feasible in around 50 per cent of pancreatic pseudocysts associated with chronic pancreatitis. Successful drainage occurred in 82-89 percent. The major complication is bleeding which required surgery for control in 5 per cent of procedures. One death attributable to the procedure has been reported. Recurrence rates range from 6 to 18 per cent with up to 4 years' follow-up. As in open surgery, recurrence is highest with drainage via the stomach. CONCLUSION: Endoscopic drainage provides a minimally invasive approach to pseudocyst management, with success and recurrence rates similar to those of open surgery but with lower morbidity and mortality rates. It should be considered the treatment of choice for pseudocysts less than 1 cm thick which bulge into the stomach or duodenum, or for those which communicate with the main pancreatic duct.

Drainage↗
PubMed1996

Surgery in South Africa.

The practice of surgery in South Africa ranges from full-time service in state-funded and academic hospitals serving a largely indigent population to a private sector for medically insured patients. Surgical training occurs at eight medical schools, and specialist registration is obtained after 4 to 5 years with either a university-conferred degree or a fellowship from the College of Surgeons of South Africa. The wide spectrum of First- to Third-World diseases and the high incidence of trauma provide comprehensive experience for practical training. Surgical standards are uniformly high, matching and sometimes pioneering the very best of Western medicine. The health care system is undergoing radical change to correct the imbalances of the apartheid era. Academic institutions are under pressure, and with incipient major financial cutbacks, there is concern that the proud record of service, teaching, and research excellence may be compromised. To facilitate the mission of broadening health care services, diploma training in surgery for rural practitioners is being developed. Outreach programs and closer liaisons with surgical societies in sub-Saharan African countries have also been initiated.

Academic Medical Centers↗
PubMed1996

Operative strategies in pancreatic trauma.

Pancreatic injuries are relatively uncommon and the choice of an appropriate operative procedure can be difficult. Operations for pancreatic trauma from January 1990 to June 1993 have been reviewed. Fifty-one patients were studied; 13 had blunt trauma, 17 gunshot wounds and 21 stab wounds. The distribution of injuries was: pancreatic head (17), body (15) and tail (19). Most patients had associated injuries of surrounding organs. Operations performed included pancreatoduodenectomy (seven), distal pancreatectomy (seven) and external drainage (35). Five patients (10 per cent) died: two from haemorrhage, one from an acute subdural haematoma and two from multiple organ failure. Ten patients (20 per cent) developed a pancreatic fistula, four following blunt trauma, four after gunshot wounds and two with stab wounds; all but one had undergone drainage procedures. Stab wounds were associated with a low incidence of duct injury and external drainage was usually satisfactory. After blunt trauma and gunshot wounds, duct injuries were common and easily missed; careful exploration by an experienced surgeon is essential. In appropriately selected patients, pancreatic resection can be performed with good result.

Adolescent↗
PubMed1996

Melanoma of the foot in white South Africans.

There have been few studies that have compared the outcome of treatment of melanoma on the sole and dorsum of the foot or defined their prognostic factors. We describe 44 white patients (30 women and 14 men, mean age 53 years) with melanoma on the foot (sole, n = 25, dorsum, n = 19) seen over a 15 year period. Forty patients presented with stage I, two with stage II, one with stage III, and one with stage IV disease. The median Breslow depth of penetration was 2.8 mm (sole 3.3, dorsum 2.3). Of the 40 patients with stage I disease, 34 patients (17 dorsum, 17 sole) were treated by wide local excision (2 cm or more) and none developed local recurrence. Six patients (five sole, one dorsum) who had narrow excision margins (less than 1 cm, stage I disease) developed local recurrences. Ten patients underwent prophylactic hyperthermic limb perfusion. Sixteen patients with stage I disease (10 sole, six dorsum) developed metastases in the inguinal nodes. All 16 underwent block dissection of the nodes and five are alive. The overall survival for both dorsum (73%) and sole (66%) (stage I disease) was similar at 60 months. Both patients with stage II disease were alive at the time of writing, but the two patients with stage III and IV disease had died. The foot is an anatomical subsite associated with a poor prognosis for melanoma. There is little difference in prognostic factors and outcome between the sole and dorsum.

Adult↗
PubMed1996

Surgical treatment of metastatic melanoma of the small bowel.

Eighteen of 1420 patients with primary cutaneous melanoma presented with symptomatic small bowel metastases and were reviewed to establish the role and efficacy of surgical intervention. The median interval between treatment of the initial skin lesion and detection of the intestinal metastases was 4.4 years (range, 2 months to 15 years). Most patients presented with either anemia, abdominal pain, bowel obstruction, or intussusception. In six patients, small bowel involvement was the first sign of metastatic disease. Seventeen of the 18 patients underwent laparotomy, and all overt metastases were completely excised in 12. Three patients died postoperatively. Fourteen of the 17 patients had satisfactory palliation with complete symptomatic relief. Median survival after resection was 13 months (range, 2 days to 300 months). Median survival of the 12 patients in whom all macroscopic disease was resected was 44.5 months (range, 2-300 months), whereas the median survival in the four with incompletely resected tumors was 4 weeks (range, 2 days-24 weeks). Five of 12 patients who underwent complete resection of small bowel metastases survived more than 6 years, 3 of whom remain well and free of disease at 6, 14, and 25 years. These results justify active surgical intervention in patients with symptomatic small bowel metastatic melanoma, both for relief of symptoms and prolongation of life.

Adolescent↗
PubMed1995

Choledochal cysts in adults.

Fourteen adults who presented with choledochal cysts were studied. Symptoms in most cases were non-specific, which resulted in delayed diagnosis. Associated extracystic hepatobiliary disease occurred in 11 patients, including two with cholangiocarcinoma. Nine patients underwent total cyst excision (eight Todani classification type I and one type II), while four with type IVa cysts had excision of the extrahepatic cyst component. There were no surgical deaths. One patient with metastases was treated conservatively. Median follow-up was 6.5 years. Two of three patients who developed anastomotic strictures underwent successful revision surgery, while one with secondary sclerosing cholangitis developed biliary cirrhosis and died from hepatic failure after 8 years. Both patients with cholangiocarcinoma have died. Ten survivors are well and one patient was lost to follow-up. This study highlights the complexity of choledochal cysts in adults and emphasizes the need for earlier diagnosis and treatment. Cyst excision should be performed where possible, with reconstruction modified to deal with the cyst type as well as associated hepatobiliary pathology.

Adolescent↗
PubMed1995

Hydatid cyst of the pancreas--a case report in a child.

Primary pancreatic hydatid disease is rare. The diagnosis may be difficult when the presentation is that of an unexplained epigastric mass, despite suggestive radiological and ultrasonic features. We describe a 12-year-old girl in whom the definitive diagnosis was only made at repeat operation, when appropriate surgical therapy was effected.

Child↗
PubMed1995

Hydatid cyst in the head of the pancreas with obstructive jaundice.

We report a rare case of obstructive jaundice caused by an intrapancreatic hydatid cyst in a 17-year-old black girl. Ultrasonography and computed tomography demonstrated the obstructing cyst in the head of the pancreas. Cyst aspiration produced clear fluid with a low amylase content and no hydatid hooklets or protoscolices. Pancreaticoduodenectomy was performed for a presumed cystic neoplasm of the pancreas, but histology showed the true diagnosis. Pancreatic hydatidosis should be considered in the differential diagnosis of obstructing pancreatic cysts in the appropriate epidemiological setting.

Adolescent↗
PubMed1995

Subungual melanoma.

Twenty (1.5%) of 1,350 patients with malignant melanoma treated during a 17-year period had their primary lesion in the nail bed. The thumb (5 patients) and big toe (7) were the most commonly involved digits. Mean delay before diagnosis was 1.4 years. Thirteen patients were black and 7 white. Eight patients (40%) were initially misdiagnosed as having traumatic, infective or benign lesions. Four patients presented with recurrent local disease after inappropriate nail excision or inadequate nail biopsy, while 2 patients had regional nodal spread and 2 had systemic metastases. Mean Breslow depth was 5.7 mm. The histogenetic subtypes were acral lentiginous melanoma (12 patients) and nodular melanoma (4 patients); 4 lesions were unclassifiable. All patients underwent amputation of the involved digit and 12 required node dissection (therapeutic in 11, prophylactic in 1). Five patients (25%) are alive (mean 52 months, range 29-99 months); 4 are disease-free and 1 has brain metastases. Overall median survival was 32 months with a 26% 5-year survival rate. Delayed diagnosis and advanced disease at presentation contributed to the poor prognosis in nail bed melanoma.

Adult↗
PubMed1995

Choledochal cyst in pregnancy: a therapeutic dilemma.

BACKGROUND: Choledochal cysts occurring in pregnant women represent a diagnostic and therapeutic challenge to a broad spectrum of the medical profession. Not only is the association rare, but the clinical signs and symptoms are obscured by physiological changes that occur during pregnancy. As a result, diagnosis is often delayed until patients present with life-threatening complications. STUDY DESIGN: This report describes three cases of choledochal cysts occurring during pregnancy. RESULTS: Although the diagnosis was initially missed in two patients, delayed treatment was not associated with an adverse outcome. In a third patient, conservative management was complicated by rupture of the cyst which resulted in fetal loss and a protracted hospital course. Definitive cyst surgery resulted in a good long-term result in all three patients. CONCLUSIONS: Although choledochal cysts rarely occur in pregnancy, clinicians need to be aware of the condition, as delayed or inappropriate therapy may be catastrophic for both mother and child. Once the diagnosis is established, patients should be referred to specialized centers where treatment can be carefully planned, bearing in mind maternal and fetal well-being, as well as the likelihood of cyst-related complications both in the short- and long-term period. Excision with reconstruction is the procedure of choice to treat this type of cyst in nonpregnant patients. In pregnancy, however, a more conservative approach may have to be adopted until the second trimester or after delivery, when the surgical risk is lowest. Elective cesarean section should be undertaken in patients in whom the cyst has not been decompressed so as to avoid the complication of cystic rupture postpartum.

Abortion, Spontaneous↗
PubMed1995

Results of 3 cm excision margin for melanoma of the scalp.

Local recurrence and survival were evaluated in 19 patients with melanoma of the scalp after conservative local treatment using a standard protocol of 3 cm excision margins and split skin grafting. Sixteen men and three women had a mean age of 46 years. 12 presented with stage I disease, one with stage II, five with stage III, and one with stage IV disease. Nodular melanoma was present in 16 patients. 17 patients had either Clark level IV or V lesions and mean Breslow depth was 3.4 mm (range 0.9-25). Local recurrence occurred in only one patient who had an excision biopsy performed. Six of 12 patients with stage I disease developed regional adenopathy and only 2 are alive after therapeutic block dissection. All patients with stage III and stage IV disease have died. Excision using 3 cm margin is adequate to control local disease. Scalp melanoma is a specific anatomical subsite associated with a high incidence of regional disease and has a poor prognosis. This high risk group of patients may benefit from elective lymph node dissection.

Adolescent↗
PubMed1995

Melanoma in black South Africans.

BACKGROUND: Scant data exists on melanoma in blacks from Africa. This study was undertaken to define factors affecting outcome of blacks from South Africa with melanoma. STUDY DESIGN: A retrospective analysis of the management and outcome of 63 black patients with malignant melanoma treated at a major referral center during a 14 year period is presented. Data evaluated included patient demographic and clinical characteristics, stage at presentation, tumor site, histologic type, treatment, and subsequent cure. Survival curves were calculated for stage and site of disease. RESULT: The mean age at presentation of the 39 women and 24 men was 60.5 years (range of 30 to 85 years), with a peak incidence in the sixth decade. The foot was the most common site of disease (45 patients). Seven patients had subungual melanoma, seven had primary mucosal lesions, and in six, the primary lesion could not be found. Thirty patients presented with stage I disease, two with stage II, 23 with stage III, and nine with disseminated metastatic disease. Acral lentiginous melanoma was the most common histogenetic type (34 patients), nodular melanoma occurred in ten patients, and superficial spreading melanoma occurred in three patients. The mean Breslow depth was 6.15 mm (range of 1 to 25 mm). Patients with localized disease were treated by wide local excision and split skin graft, while patients with melanoma in the nailbed were treated by amputation of the involved digit. Sixteen patients are alive after a mean follow-up period of 82.1 months, 44 have died after a mean of 12.7 months, and five patients have been unavailable for follow-up evaluation. CONCLUSIONS: The poor prognosis in black patients in South Africa is the result of delayed presentation with thick primary lesions and advanced disease. An active education program may reduce mortality by detecting the disease earlier.

Adult↗
PubMed1994

Primary sclerosing cholangitis. Requiem for biliary drainage operations?

OBJECTIVE: To review the outcome of a consecutive number of patients with primary sclerosing cholangitis (PSC) treated at one institution to define prognostic variables and determine the influence of surgery on outcome. DESIGN: Case series of patients with PSC seen in Cape Town, South Africa, between 1981 and 1991. SETTING: Tertiary referral center. PATIENTS: Thirty-six patients with PSC were studied. Diagnosis was based on cholangiographic findings of multiple strictures of the bile ducts together with compatible clinical and biochemical features. Thirty-two patients were followed up prospectively for up to 9 years. MAIN OUTCOME MEASURES: Patient outcome was defined as good (stable or slowly progressive disease) or poor (death or liver transplantation). RESULTS: During the follow-up period, seven patients with PSC died and two underwent liver transplantation. Actuarial survival at 5 years was 52%. An increased serum bilirubin concentration was the only variable at presentation that independently predicted a poor outcome. Cholangiography was unhelpful in predicting patient outcome. Six patients who developed obstructive jaundice associated with advanced liver disease underwent biliary drainage operations for surgically correctable strictures, but this did not seem to prevent progression of the disease. Two patients who progressed to end-stage liver disease went on to have liver transplantation and were alive with functioning grafts at 7 and 14 months, respectively. CONCLUSIONS: Symptomatic PSC is a progressive disorder with a poor prognosis. Our experience suggests that patients with advanced liver disease caused by PSC should be considered directly for liver transplantation rather than biliary bypass operations.

Adolescent↗
PubMed1994

Endoscopic drainage of traumatic pancreatic pseudocyst.

Pancreatic pseudocyst following trauma is usually caused by a major duct injury and may present late. The outcome of endoscopic treatment in five patients with post-traumatic pseudocyst is described. Diagnosis was made from 3 weeks to 1 year after injury by ultrasonography and computed tomography. A distinct bulge was visible in the stomach or duodenum using endoscopic retrograde cholangio-pancreatography, and a cyst enterostomy was established with a knife or standard papillotome. Successful drainage was achieved without complications. One patient developed a recurrence, which was redrained endoscopically, but surgical intervention was required for persistent pain. Early results suggest that endoscopic drainage for selected pancreatic pseudocysts is feasible and safe.

Adult↗
PubMed1994

A 15-year experience of injection sclerotherapy in adult patients with extrahepatic portal venous obstruction.

OBJECTIVE: The authors report a 15-year experience with injection sclerotherapy in the management of adult and teenage patients with esophageal varices due to extrahepatic portal venous obstruction (EHPVO). SUMMARY BACKGROUND DATA: Extrahepatic portal venous obstruction is an uncommon cause of esophageal varices and is associated with normal liver function. Effective control of variceal bleeding is the major factor influencing survival. The results of surgery have been unsatisfactory, and therefore, more conservative management policies have been adopted. METHODS: Fifty-five patients with proven EHPVO underwent repeated injection sclerotherapy via either a modified rigid esophagoscope under general anaesthesia or a fiber-optic endoscope under light sedation, using ethanolamine oleate as the sclerosant. RESULTS: Esophageal varices were eradicated in 44 patients after a median number 6 injections (range 1-17) over a mean of 12.5 months (range 1-48). The mean follow-up was 6.8 years (range 1.1-14.6 years). Eleven patients were admitted on eighteen occasions with bleeding from esophageal varices before eradication and there were seven bleeding episodes in six patients from recurrent varices after initial eradication. Complications related to sclerotherapy included injection site leak (6), stenosis (11) and mucosal ulceration (32) during 362 injection sclerotherapy episodes. Four patients died during the study period. CONCLUSIONS: Injection scelotherapy is the treatment of choice in most patients with EHPVO.

Adult↗